Small-Bowel Capsule Endoscopy in Clinical Practice: Has Anything Changed Over 13 Years?

How to Study the Effects of Dietary Lipids on the Small Intestinal Microbiome? Methodological Design and Evaluation of the Human HealThy fAt, haPpy mIcRobiome (TAPIR) Proof-of-Concept Study

Background

Emerging evidence highlights the importance of the small intestinal microbiota in digestion and metabolism, underscoring the challenging need for human studies beyond fecal analyses.

Objective

The TAPIR (acronym of "healthy fat, happy microbiome") proof-of-concept study was primarily designed to confirm the interaction between the small intestinal microbiota and dietary lipids in healthy adults with a challenge test. We also aimed to assess the impact of a plant-based mild-ketogenic preconditioning diet on microbiome composition and function. Here, we comprehensively describe our extensive study protocol and evaluate the study execution.

Methods

Participants consumed an 8-day preconditioning diet, followed by a high-fat shake challenge test on day 9. During this test, fasting and postprandial small intestinal aspirates were collected every 20 min via a naso-intestinal catheter, and blood samples were collected hourly. Participants ingested small intestine aspiration capsules before (day 0), on day 6 of the preconditioning diet, and during the challenge test. Dietary compliance, capsule retrieval, sample collection, stool pattern, and gastrointestinal complaints were monitored to evaluate study execution.

Results

Twenty adults with a mean age of 48 y (19-88 y) and a mean body mass index (BMI) of 24.3 kg/m2 (19.5-30 kg/m2) consumed a preconditioning diet with a 96% compliance. There were no significant changes in gastrointestinal complaints and stool patterns during the study. Mean aspiration capsule retrieval rate was 94.7%, with mean sample weights per timepoint between 84.2 and 95.4 mg and median transit times between 32.8 and 49.3 h. The average success rate of aspirate collection by catheter was 49%, varying significantly between time points.

Conclusion

The dietary intervention was successful and well-tolerated. We sampled in the small intestine with capsules and catheters, each with its own (dis)advantages. The comprehensive description and evaluation of our study execution offer practical insights supporting future study designs in food-microbe interactions in the small intestine.The trial is registered at clinicaltrials.gov as NCT06064266.

Predictors of Positive Video Capsule Endoscopy Findings for Chronic Unexplained Abdominal Pain: Single-Center Retrospective Study and Meta-Analysis

Video capsule endoscopy (VCE) is an effective diagnostic modality for detecting small bowel lesions. However, the value of VCE for patients with chronic recurrent abdominal pain (CAP) of unknown etiology remains obscure. We retrospectively analyzed factors that could predict enteropathy based on the medical records of 65 patients with unexplained chronic recurrent abdominal pain (CAP) who were assessed using VCE between 2001 and 2021. We also conducted a systematic review and meta-analysis of the literature to validate our results. The positive findings of 27 (41.5%) of the 65 patients were mostly ulcerative lesions including stricture (n = 14, 60.9%) and erosion (n = 8, 29.7%). Multivariate analysis identified elevated ESR (OR, 1.06, 95% CI, 1.02–1.1, p = 0.004) as a significant risk factor for enteropathy predicted by VCE. Three eligible studies in the meta-analysis included 523 patients with CAP. Elevated C-reactive protein (CRP) (OR, 14.09; 95% CI, 2.81–70.60; p = 0.001) and erythrocyte sedimentation rate (ESR) (OR, 14.45; 95% CI, 0.92–227.33; p = 0.06) indicated VCE-positive findings in patients with unexplained abdominal pain. Elevated levels of the inflammatory markers ESR and CRP can thus predict positive VCE findings in patients with CAP.

Capsule Endoscopy: Pitfalls and Approaches to Overcome

Capsule endoscopy of the gastrointestinal tract is an innovative technology that serves to replace conventional endoscopy. Wireless capsule endoscopy, which is mainly used for small bowel examination, has recently been used to examine the entire gastrointestinal tract. This method is promising for its usefulness and development potential and enhances convenience by reducing the side effects and discomfort that may occur during conventional endoscopy. However, capsule endoscopy has fundamental limitations, including passive movement via bowel peristalsis and space restriction. This article reviews the current scientific aspects of capsule endoscopy and discusses the pitfalls and approaches to overcome its limitations. This review includes the latest research results on the role and potential of capsule endoscopy as a non-invasive diagnostic and therapeutic device.

Feasibility and diagnostic yield of small-bowel capsule endoscopy in patients with surgically altered gastric anatomy: the SAGA study

BACKGROUND AND AIMS

Little is known about small-bowel (SB) capsule endoscopy (CE) in patients with a history of gastric surgery. This study aims to evaluate the feasibility and diagnostic yield (DY) of orally ingested SB-CE in patients with surgically altered gastric anatomy.

METHODS

Twenty-four European centers retrospectively identified patients who had SB-CE after total or subtotal gastrectomy. The primary outcome was the DY of SB-CE (intermediate P1 to highly P2 relevant findings). Secondary outcomes were gastric and SB transit times, completion, cleanliness, and adverse event rates.

RESULTS

Studied were 248 procedures from 243 patients (mean age, 62 years) with a history of partial gastrectomy (Billroth I, 13.1%; Billroth II, 34.6%), total gastrectomy (7.4%), Whipple procedure (12.8%), sleeve gastrectomy (7.2%), or gastric bypass surgery (24.7%). Obscure GI bleeding was the most frequent indication (85.1%). SB completion rate was 84.3%. One capsule retention in the SB was noted (adverse event rate, .4%). Median SB transit time was 286 minutes (interquartile range [235; 387]). Cleanliness was rated as adequate in 92.1% of procedures. After exclusion of abnormalities found at the upper anastomotic site, the DY was 43.6%, with inflammatory/ulcerated lesions observed more frequently (23.4%) than vascular lesions (21.0%).

CONCLUSIONS

SB-CE seems to be feasible and safe in selected patients with a history of major gastric surgery and comes with a high DY. The spectrum of abnormal SB findings in these patients may be different from what is known from the literature in nonoperated patients.

The Detective Value of Magnetically Controlled Robotic Capsule Endoscopy in Patients With Suspected Small Intestinal Disease

Objective: To explore the detective value of magnetically controlled robotic capsule endoscopy (MCRCE) in patients with suspected small intestinal disease.

Patients and Methods: In total, 1,802 patients with suspected small intestinal disease and negative gastroenteroscopy from Shanghai Jiao Tong University Affiliated Sixth People's Hospital were examined with MCRCE, and the data were collected for further analysis.

Results: Among the 1,802 patients who were examined with MCRCE, 974 were diagnosed with small intestinal disease, reaching a positive detection rate of 54.1%. The five most common conditions that were detected include non-specific enteritis in 722 cases (40.1%), small intestinal ulcers in 87 cases (4.8%), abnormal small bowel evacuation in 45 cases (2.5%), small intestinal bleeding in 33 cases (1.8%), and small intestinal yellow spots in 31 cases (1.7%). The running time of the capsules in the small intestine ranged from 85–437 min, with an average of 210.24 ± 89.08 min. No complications, such as intestinal obstruction or capsule retention, were observed in all patients.

Conclusion: MCRCE is a safe and non-invasive endoscopic examination with a highly accurate detection rate for small intestinal diseases.

Small bowel capsule endoscopy: where do we stand after 20 years of clinical use?

Small bowel capsule endoscopy (SBCE) was introduced into clinical practice almost 20 years ago and, nowadays, it is an essential tool for the study of the small bowel. SBCE allows a radiation-free examination of the entire mucosal surface of the small bowel with high-quality images, limited invasivity and a good safety profile. Nevertheless, the main limitation of SBCE is the lack of any possible direct therapeutic intervention. Indications for SBCE have evolved throughout the years, from "old" ones such as suspected small bowel bleeding (still the main indication for SBCE) to newer ones such as refractory celiac disease, hereditary polyposis syndromes and Crohn's disease. Thus, nowadays SBCE has a key role in the diagnostic algorithms in many conditions. Furthermore, the introduction in the SBCE field of cutting-edge technologies, as artificial intelligence systems, is likely to shorten the reading time making SBCE even more effective and easy to perform. Preliminary data are extremely promising and solid evidence is being gathered by current studies.

Adverse events of video capsule endoscopy over the past two decades: a systematic review and proportion meta-analysis

BACKGROUND

A full spectrum of video capsule endoscopy (VCE) adverse events over the past two decades has not been evaluated. We aimed to determine pooled rates, predictors and temporal-trend of VCE adverse events over the past two decades.

METHODS

Systematic search of PubMed and EMBASE for English-language publications reporting VCE adverse events (January 1, 2000 to March 31, 2019). Data were extracted independently by two investigators. Pooled VCE adverse event rates were calculated using the random or fixed model as appropriate. Predictors and temporal-trend of each adverse event were performed by meta-regression analyses.

RESULTS

In total, 402 studies were identified, including 108,079 VCE procedures. Rate of retention, swallow disorder, aspiration, technical failure, and procedural adverse events were 0.73% (95% confidence interval [CI] 0.59-0.89%), 0.75% (95% CI 0.43-1.13%), 0.00% (95% CI 0.00-0.00%), 0.94% (95% CI 0.65-1.28%), 0.67% (95% CI 0.32-1.10%), respectively; incomplete examination rate of esophagus, stomach, small bowel, and colon were 9.05%, 7.69%, 12.08%, 19.19%, respectively. Patency capsule reduced retention rate by 5.04%, whereas known inflammatory bowel disease increased retention rate by 4.29%. Elder was the risk and protective factor for small bowel incomplete examination (0.30%) and swallow disorder (- 0.72%), respectively. Rates of retention and small bowel incomplete examination significantly declined over time (P = .0006 and P < .0001)..

CONCLUSIONS

VCE adverse event rates were generally low, and retention and small bowel incomplete examination rates declined over the past two decades. Patients with known inflammatory bowel disease or elder should be alerted to high risk of retention or small bowel incomplete examination (PROSPERO: CRD42019139595).

Indications and diagnostic yield of small-bowel capsule endoscopy in a real-world setting

Background

Indications and diagnostic yield of small-bowel video capsule endoscopy (SB-VCE) are communicated in recent clinical academic guidelines. However, guidelines are based mainly on relatively few, small, selection-biased studies at experienced centers, and thus we lack information on indications and diagnostic yield of SB-VCE in the real-world community setting. The aim of the study was to evaluate indications and diagnostic yield of SB-VCE in the real-world community setting.

Methods

Our local VCE clinical database was used to identify patients undergoing SB-VCE procedures over a 7-year period (2011–2018). Patients were broadly referred and underwent SB-VCE using PillCam™ SB 2 and SB 3 capsule systems. Procedures were reviewed by local endoscopists, who had undergone similar formal SB-VCE review training. Medical reports of the procedures were composed as such. We retrospectively reviewed all reports and gathered data regarding indications and findings. Diagnostic yield was considered positive if SB-VCE visualized any type of clinically significant pathological finding.

Results

536 SB-VCE procedures in 516 patients were included in final assessment. Patient mean (± SD) age was 50 ± 20 years with approximately even female/male ratio (275:241). The overall proportion of positive findings was 42% (225/536). The two main indications were obscure gastrointestinal bleeding (occult/anemia or overt/active, OGIB) of 46% (246/536) and definite/suspected Crohn’s disease (CD) of 39% (210/536). Positive SB-VCE findings were obtained in 44% (108/246) of procedures with indication of OGIB and in 50% (104/210) of procedures with indication of CD.

Conclusions

The indications for SB-VCE are largely consistent with guidelines but with an apparently relatively low diagnostic yield in our real-world community setting.

Adherence to European Society of Gastrointestinal Endoscopy recommendations of endoscopists performing small bowel capsule endoscopy in Italy

BACKGROUND

The European Society of Gastrointestinal Endoscopy (ESGE) has recently issued a technical review focused on small bowel capsule endoscopy (SBCE).

AIM

To compare SBCE current practice in Italy to ESGE technical recommendations.

MATERIAL AND METHODS

A dedicated per-centre semi-quantitative questionnaire was prepared by a group of SBCE experts. One-hundred-fifty Centres were invited to participate in the data collection concerning SBCEs performed between June 2016 and June 2017. Data were compared with ESGE recommendations.

RESULTS

120 Centres participated in the data collection. Current practices agreed with ESGE recommendations in 56.3% (9/16) of the issues evaluated. Differences between ESGE recommendations and current practice concerned the management of patients with pacemakers or cardiac implantable defibrillators (which was in agreement with ESGE recommendations in 31.7% and 15.8% of Centres, respectively), the SBCE setting (only 51% of SBCEs were performed as outpatients procedures), the assessment of capsule excretion (timing and modality were in agreement with ESGE recommendation in 20.0% of Centres), and in the involvement of trained nurses or fellows in training as pre-readers (7/120; 5.8%).

CONCLUSIONS

Although SBCE is widely used and largely available in Italy, there are still some technical, practical and organizational issues that can be modified to bridge the gap between current practice and ESGE guideline recommendations.

Capsule Endoscopy and Enteroscopy in Celiac Disease

Celiac disease predominantly involves the proximal small bowel, but villus atrophy can be patchy, spare the duodenum, and be present more distally. Video capsule endoscopy is more sensitive than standard endoscopy to detect villus atrophy, and can define extent of disease, though it cannot obtain biopsies. Duodenal biopsy is the gold standard for diagnosis. Video capsule endoscopy assists in special circumstances when biopsy is not possible, and in equivocal diagnosis. Video capsule endoscopy and enteroscopy are recommended for evaluating complicated celiac disease, especially refractory celiac disease type II. Future developments include computer-assisted capsule programs and advanced capsule and enteroscope design.